Podcast Summary: The OCD Stories – Episode 503

Title: Samantha Faden & Dr. Jenifer Cullen: Successfully Adjusting OCD Therapy for Autistic Clients
Host: Stuart Ralph
Guests: Samantha Faden (autistic, lived experience with OCD) & Dr. Jenifer Cullen (clinical psychologist, McLean OCD Institute)
Date: September 14, 2025

Episode Overview

In this insightful episode, host Stuart Ralph welcomes Samantha Faden and Dr. Jenifer Cullen to discuss their therapeutic relationship and the nuanced adjustments needed when providing OCD therapy to autistic clients. Drawing from their five-year client-therapist relationship, Sam and Jen candidly discuss their shared journey, detailing successes, mistakes, and discoveries. This conversation is highly relevant for OCD clinicians, autistic individuals navigating mental health support, and anyone interested in advancing neurodiversity-informed therapeutic practice.

Major Discussion Points & Insights

1. Introductions & Relationship Background ([03:09–04:38])

• Sam describes herself as Jen’s “favorite patient, client, whatever you want to call me,” noting her dual experience with OCD and autism, and experience working with autistic populations herself.
• Dr. Cullen shares her extensive background (close to 30 years) specializing in OCD and OCD-spectrum disorders.
• The two have worked together for over five years, creating a collaborative dynamic rooted in honesty and adaptability.

2. Sam’s Therapy Journey: From Hair-Pulling to Diagnosis ([04:48–06:39])

• Sam originally sought therapy for trichotillomania (hair-pulling).
• Neither Sam nor previous clinicians recognized her OCD or autism until Jen did.
• Their work shifted dramatically upon realizing the overlap of autism and OCD; they focused on life engagement and functional, not just symptomatic, therapy.

3. Differentiating OCD and Autism Behaviors ([08:24–11:28])

• Dr. Cullen explains:

  “I’ll look at the function of a behavior, and if it is fear-based, then that’s sort of easier to tell us that it’s probably related to OCD. If not…and it’s to regulate sensory sensations…then we know it’s related to autism.” (Dr. Cullen, [08:26])

• Sam emphasizes the importance of identifying whether an intervention is functional for life engagement or just “an exposure for no good reason.”
• Therapy required active “pulling apart” of what is truly OCD-driven vs. autistic processing.

4. Learning from Mistakes: Therapy “Rupture and Repair” ([11:28–13:11])

• Dr. Cullen shares a key mistake: treating Sam’s sensory comfort objects (her blanket) as exposure targets when they were vital for regulation.
• Sam recalls the incident with humor now, noting she is “no filter” with Jen, demonstrating deep trust and real-world repair.
• The pair highlight that rupture and honest conversation actually strengthened their alliance.

5. Adjusting ERP for Autistic Clients

a. Sensory Overload Planning ([14:34–18:18])

• Jen explains the necessity of a “sensory overload plan” before starting ERP:

  “There’s no new learning that occurs when an autistic client is completely sensory overloaded...and we want new learning to occur during ERP.” (Dr. Cullen, [17:32])

• Breaks and grounding/self-stim (“stimming”) are encouraged, unlike standard ERP.
• Sensory tools/objects (e.g., hats, headphones) are not automatically “compulsions”—they may be vital regulation tools.

b. Concrete, Predictable Structure ([25:31–28:22])

• Traditional unpredictable, mixed-mode ERP is often counterproductive; predictability and stepwise progression are emphasized.
• Jen: “We’re setting up ERP to be autistic. Right. So we’re introducing more predictability.”
• Shorter, more frequent sessions recommended if sensory load is reached.

c. Tailoring Measurement & Motivation ([21:07–24:23])

• Standard scales (e.g., SUDS 0-100) felt abstract; Sam co-created her own rating system tied to her special interests (aircraft, numbers).
• Involving special interests (e.g., JetBlue) improved buy-in and engagement.
• Therapy linked to Sam’s values/interests (“special interest-based exposure”).

d. Negotiation & Buy-In ([28:22–31:13])

• Sam and Jen developed collaborative, numerical negotiation for reducing compulsions (“as many as this, then fewer next time”).
• Sam notes: “My voice feels more heard...I have enough knowledge and progress that I can make a fair plan.”

6. Language and Identity: Moving Beyond the Medical Model ([33:08–36:47])

• Shift from “person with autism” to “autistic person/client”—recognizing autism as an integral, not pathological, identity.
• Critique of “functioning labels” (high/low) as oversimplifying and misleading.
• Rejecting deficit-based metaphors (“the puzzle piece”, “exploding brain”): “Autistic individuals don’t want to be this puzzle that we non-autistics have to solve.” (Dr. Cullen, [35:42])

7. Motivation, Hope, and Words of Encouragement ([38:47–45:40])

• Sam credits feeling heard and constructive feedback (“show me what you did, you lived to tell!”) as motivating.
• Jen emphasizes the effectiveness and increasing spread of these tailored approaches:

  “Changing up the way we do ERP with our autistic clients, it works. It really works.” (Dr. Cullen, [44:08])

• Sam offers honest hope: “There is a place that can be safe and encouraging to engage in treatment, especially when you’re in this place that feels like nobody understands you...and it’s getting bigger.” ([45:30])

Notable Quotes & Memorable Moments

• On learning from clients:

  “I’ve learned more from Sam and my other autistic clients than any book I could have ever read.”
  — Dr. Jen Cullen ([06:39])

• On honesty in therapy:

  “I have no filter when it comes to [Jen] at this point.”
  — Sam ([13:35])

• On ERP adaptation:

  “We’re setting up ERP to be autistic.”
  — Dr. Jen Cullen ([25:39])

• On the value of repair:

  “All that matters is can you repair it? And the fact that you guys are here doing a podcast shows that actually, you repaired it.”
  — Stuart Ralph ([13:01])

• On shifting language:

  “We really want to start to see the autistic client as somebody with neurodiverse tendencies instead of...a disorder where we need to do treatment on their symptoms.”
  — Dr. Jen Cullen ([35:55])

• On hope and progress:

  “There is a place that can be safe and really encouraging to engage in treatment...I just think that there is a place we can fit in and it’s getting bigger and more inclusive and welcoming.”
  — Sam ([45:39])

Key Timestamps

• Introductions & Therapy Background: 03:09–04:38
• Diagnosis Journey: 04:48–06:39
• OCD vs. Autism Behaviors: 08:24–11:28
• Rupture and Repair Example: 11:28–13:11
• Adjusting ERP: Sensory & Structure: 14:34–18:18, 25:31–28:22
• Customizing Scales via Special Interests: 21:07–24:23
• Negotiation & Buy-In: 28:22–31:13
• Language & Identity: 33:08–36:47
• Motivation & Words of Hope: 38:47–45:40

Takeaways for Clinicians & Clients

• Be collaborative: Let autistic clients co-author their exposure plans, including sensory needs and special interests.
• Be concrete and structured: Abstract concepts and unpredictable therapy can trigger disengagement.
• Practice rupture and repair: Honest mistakes can lead to stronger therapeutic alliances when openly discussed.
• Shift language and assumptions: Uphold neurodiversity, avoid deficit models, and use preferred identifiers.
• Therapy works when it fits: Tailored approaches are not only more humane but also more effective and sustainable.

For Further Listening:

Check out more episodes from The OCD Stories and read or listen to more about ERP, autism, and neurodiversity-affirming care.

This summary was created to provide an in-depth, accessible synthesis of the episode’s major themes, discussions, and actionable insights for the OCD, autism, and clinical community.